Ophthalmic Epidemiology, 17(4), 225–233, 2010

Copyright © 2010 Informa UK Ltd

ISSN: 0928-6586 print/ 1744-5086 online
DOI: 10.3109/09286586.2010.489250

ORIGINAL ARTICLE

A Survey of Visual Impairment and Blindness

in Children Attending Four Schools for the
Blind in Cambodia
David I.T. Sia,1 James Muecke,2 Michael Hammerton,1 Meng Ngy,3 Aimee Kong,1
Anna Morse,1 Martin Holmes,1 Horm Piseth,4 Carolyn Hamilton,5 and
Dinesh Selva6
South Australian Institute of Ophthalmology, Adelaide, Australia
1

South Australian Institute of Ophthalmology, Discipline of Ophthalmology & Visual Sciences, University of Adelaide
2

and Department of Ophthalmology, Women’s and Children’s Hospital, Adelaide, Australia

3
National Program for Eye Health, Cambodia
4
The Fred Hollows Foundation, Australia
5
Guide Dogs Association of SA & NT Inc., Adelaide, Australia
6
South Australian Institute of Ophthalmology, and Discipline of Ophthalmology & Visual Sciences, University of
Adelaide, Adelaide, Australia

ABSTRACT
Purpose: To identify the causes of blindness and severe visual impairment (BL/SVI) in children
attending four schools for the blind in Cambodia and to provide spectacles, low vision aids, ori-
entation and mobility training and ophthalmic treatment.
Methods: Children < 16 years of age were recruited from all 4 schools for the blind in Cambodia.
Causes of visual impairment and blindness were determined and categorized using World Health
Organization methods.
Results: Of the 95 children examined, 54.7% were blind (BL) and 10.5% were severely visually
impaired (SVI). The major anatomical site of BL/SVI was the lens in 27.4%, cornea in 25.8%,
retina in 21% and whole globe in 17.7%. The major underlying etiologies of BL/SVI were heredi-
tary factors (mainly cataract and retinal dystrophies) in 45.2%, undetermined/unknown (mainly
microphthalmia and anterior segment dysgenesis) in 38.7% and childhood factors in 11.3%. Avoid-
able causes of BL/SVI accounted for 50% of the cases; 12.9% of the total were preventable with
measles being the commonest cause (8.1% of the total); 37.1% were treatable with cataracts and
glaucoma being the commonest causes (22.6% and 4.8% respectively). More than 35% of children
required an optical device and 27.4% had potential for visual improvement with i­ ntervention.
Conclusion: Half of the BL/SVI causes were potentially avoidable. The data support the need for
increased coverage of measles immunization. There is also a need to develop specialized pediatric
ophthalmic services for the management of surgically remediable conditions, to provide optom-
etric, low vision and orientation and mobility services. Genetic risk counseling services also may
be considered.
Keywords:  Children; Blindness; Visual impairment; Blind school; Cambodia

Received 10 January 2010; Revised 08 March 2010;

Accepted 14 April 2010

Correspondence: David Ik Tuo Sia, South Australian Institute of

Ophthalmology, Royal Adelaide Hospital, North Terrace, Adelaide,
South Australia 5000, Australia. E-mail: daviditsia@gmail.com

225
226    D. I. T. Sia et al.
INTRODUCTION
The control of blindness in children is considered a high
priority of the World Health Organization’s (WHO’s)
“VISION 2020–The Right to Sight” global initiative.1
Although childhood blindness is relatively uncommon,
it is a priority of Vision 2020 for several reasons: the
number of “blind years” in children is almost equal to
the number of blind years due to age-related cataract;
many of the causes of blindness in children are either
preventable or treatable; and many of the conditions
associated with childhood blindness also cause child
mortality (eg, measles, congenital rubella syndrome,
vitamin A deficiency) and so the control of blindness
in children is closely linked to child survival.1
The prevalence of blindness in children ranges from
approximately 0.2–0.3/1000 children in developed
countries to 1.5/1000 children in developing coun-
tries.2 It is estimated that three-quarters of the world’s
blind children live in the poorest regions of Africa and
Asia.1 The causes of childhood blindness differ mark-
edly between different regions, apparently related to
socioeconomic factors.3 In very low-income regions,
corneal scarring secondary to vitamin A deficiency,
measles keratitis or ophthalmia neonatorum is the
main cause of childhood blindness. In some of these
countries, cataract is now assuming greater importance
as the economies are improving.4
Reliable population-based data on the causes of
blindness in children are difficult to obtain, as such
surveys require very large samples, making them
extremely labor-intensive and costly. Examination of
children enrolled in schools for the blind has the advan-
tage of enabling a large number of children to be exam-
ined relatively quickly by a few examiners, however
has the disadvantage of inherent selection bias.5
Cambodia is a low-income country situated in
South East Asia, bordered by Vietnam, Thailand and
Laos. It comprises 24 provinces and has a population
of 13.4 million people, of which 5.1 million (38%) are
under 15 years of age.6 The population is made up of
90% Khmer, 5% Vietnamese, 1% Chinese and 4% other
ethnicities. No study on the causes of childhood blind-
ness in Cambodia has yet been reported. This study
was undertaken to determine the causes of blindness
and severe visual impairment (BL/SVI) in children
attending all schools for the blind in Cambodia and to
identify preventable and treatable causes.
MATERIALS AND METHODS
Children attending all four schools for the blind in
Cambodia were examined over a one-week period in
March 2009. Written consent was obtained from the
principal of each school if the parents were not avail-
able. All children gave verbal consent.
Relevant information was collected from school
staff, children, and medical records. A brief history of
onset of visual loss, family history, history of consan-
guinity, ethnic group and place of residence was taken.
A detailed eye examination was performed by a team
of Australian and Cambodian optometrists and oph-
thalmologists. Distance visual acuity was measured
for each eye using a LogMar LEA chart, and near-
vision was assessed using 5 mm shapes (square, circle,
­triangle), and a series of large (50 mm), high contrast,
matching shapes. Functional vision was assessed by
asking each child to navigate unassisted around two
chairs placed one meter apart. Visual fields were
assessed by confrontation. The anterior segment was
assessed by an Australian and a Cambodian ophthal-
mologist together using slit lamp biomicroscopy. The
posterior segment was evaluated by indirect or direct
ophthalmoscopy with dilatation of the pupil.
Visual loss was classified according to the WHO
categories of BL/SVI.7 Blindness (BL) is defined as
visual acuity (VA) < 3/60 in the better eye, severe visual
impairment (SVI) as VA < 6/60 to 3/60 in the better
eye, and visual impairment as VA < 6/18 to 6/60 in the
better eye.
Children who had distance vision of better than no
perception of light (NPL) or were “believed to have
useful residual vision” (when formal testing of visual
acuity was not possible but the child was believed to
have sufficient residual vision for independent mobil-
ity, for making social contacts or for near vision),9
underwent refractive testing and low vision assess-
ment by an Australian and Cambodian optometrist.
Pin-hole acuity was tested using a multiple pin-hole
occluder and tumbling-E chart at 3 meters, illumi-
nated by natural sunlight or ambient room lighting.
The chart was moved closer in logarithmic steps to
measure VA < 6/120 (3/60). Care was taken to ensure
that background glare was minimised, (eg, sunlight
through a window adjacent to the chart was blocked).
Pin-hole acuity was not assessed in cases where it
would obviously not improve vision (eg, complete
central corneal opacification, macular or optic nerve
pathology). Pin-hole acuity merely served as a gauge
for potential VA improvement with refraction. A lack
of improvement with pin-hole testing did not preclude
assessing refraction, given the nature and severity of
visual reduction and possible use of eccentric fixa-
tion.
Distance refraction was determined primarily
by retinoscopy, using a trial frame and loose lenses.
Refraction was subjectively refined by assessing
visual improvement with ± 2 diopter (D) lenses, then
bracketing with ± 1D and ± 0.5 diopter sphere (DS)
Ophthalmic Epidemiology

lenses for the spherical component. Astigmatism was
assessed ­initially using a ± 1 Jackson cross-cylinder (for
VA ≤ 6/48), and refined using a ±  0.50 cross-cylinder
(for VA>6/48). Cylinder axis was bracketed to within
5o steps and cylindrical power to within 0.50 diopter
cylinder (DC). Best-corrected visual acuity was tested
with each eye separately, then together (unless NPL in
the worse eye). Where refraction improved the acu-
ity, distance spectacles were ordered and dispensed
locally.
Near vision was tested binocularly using 5mm
shapes (square, circle, triangle), and a series of large
(50 mm), high contrast, matching shapes. Working
distance was not specified in the near vision mea-
surement, encouraging children to adopt their usual
posture when attempting to read. When the large
matching shapes were discernible, low vision assess-
ment was conducted. Low vision aids (LVAs) were
introduced in order of ease of use and magnification
strength: (1) high plus spectacles, (2) stand magnifiers,
(3) spectacle-mounted loupe magnifiers, (4) block/
visuallete bright-field magnifiers. Trialed magnifica-
tion was selected based upon each child’s relative ease
of “reading” the 5mm shapes.
A LEA near chart, with a matching card, was used
to assess near acuity with the LVA, for both the right
and left eyes (if applicable). Each child was offered at
least two LVA options, and their use demonstrated.
Ultimate selection of an LVA was determined primar-
ily by the near vision outcome, but also according to
the child’s demonstrated ease and preference for a
particular aid.
The ophthalmologists recorded the major site of
abnormality leading to visual loss for each eye and for
the child using the WHO classification system in the
coding instructions.9 When the major site of abnormal-
ity was different for the two eyes, the most prevent-
able or treatable abnormality was selected. If neither
eye had preventable or treatable abnormalities, the
abnormality that occurred most recently was selected.
If it was not known which abnormality occurred most
recently, the eye with better vision was selected. The
main etiology of visual loss was recorded for each eye
and for the child. When the etiology was different for
each eye, the etiology selected for the child was that
of the major site of abnormality. The need for optical,
surgical or medical interventions was recorded and
the visual prognosis assessed.
All data were recorded using the WHO Prevention
of Blindness (PBL) eye examination record for chil-
dren.8 Data were entered into a database in Microsoft
Excel (Seattle, WA, USA) and analyzed using SPSS
V.17.0 (Chicago, IL, USA) statistical software.
A qualified instructor assessed orientation and
mobility (O&M) training available to teachers and
© 2010 Informa UK Ltd
Childhood Blindness in Cambodia    227
students. The instructor consulted with the principals
and teachers at each of the schools with the aim of
identifying future needs and training opportunities. In
most cases, it was not possible to conduct individual
student assessments or provide individual training,
given the complexities of O&M and the time required
to develop individually tailored programs. Thus, con-
sultation and training of the teachers was deemed to
be of greater, long-term sustainable value in providing
for the needs of the students at the schools. One-off
introductory training sessions were conducted with
teachers and students in sighted guide and long cane
skills at each school. O&M curriculums were assessed
and suggestions for development were made.
Ethical Approval
Permission to visit schools was granted by the Ministry
of Health, Cambodia. The study protocol adhered to
the tenets of the Declaration of Helsinki and approval
was obtained from the National Ethics Committee for
Health Research in Cambodia and the Royal Adelaide
Hospital Research Ethics committee.
RESULTS
Of the 100 students enrolled in the schools, 4 were
excluded from the survey due to sickness and 1 was
excluded due to absence. A total of 95 students were
examined in 4 schools for the blind from 4 of the 24
provinces in Cambodia (see Table 1). Fifty-four stu-
dents (56.8%) were male and 41 (43.2%) were female.
The median age was 13 years with a range of 6 to
15 years. The total number of children with BL/SVI
was 62 (65.3%); 52 (54.7%) children were blind and 10
(10.5%) had severe visual impairment (see Table  2).
Twenty-six children were visually impaired and 7
had no impairment in the better eye. These 7 children
without visual impairment attended schools for the
blind because they had visually impaired siblings at
the same school and it was easier for their parents to
have them together. All subsequent analyses are for
the 62 children (65.3%) with BL/SVI.
All the children examined were of the Khmer eth-
nic group and the majority of them had no associated
physical or mental disabilities (57, 91.9%). Visual loss
was present since birth in 74.2% (46) and occurred in
the first year of life in 11.3% (7). Family history of eye
disease was found in 37.1% (23), with the majority of
these having cataract (11, 47.8%) and retinal dystrophy
(5, 21.7%). A history of consanguineous marriage was
present in 17.7% (11) and accounted for 43.5% (10) of
children with a positive family history of eye disease.
228    D. I. T. Sia et al.

TABLE 1  Demographic characteristics of the study population the contralateral eye, 1 had both eyes removed, and 1 had
Number % unknown surgery. Of the 10 children who had under-
School gone cataract surgery, 6 had intraocular lens implants, 1
  Krousar Thmey, Siem Reap 13 13.7% was aphakic and the remaining 3 were unspecified.
  Krousar Thmey, Battambang 15 15.8%
  Krousar Thmey, Phnom Penh 25 26.3%
  Krousar Thmey, Kampong Cham 42 44.2% Anatomical Classification of Visual Loss
Gender (Table 3)
  Male 54 56.8%
  Female 41 43.2% The major anatomical sites of abnormality were the lens
Age (27.4%), cornea (25.8%), retina (21.0%) and whole globe
  0–5 1 1.1% (17.7%). Cataract (15, 24.2%) was the most common
  6–10 20 21.1% abnormality of the lens; 7 of these children (46.7%) had
  11–15 74 77.9% unoperated cataract, and 8 (53.3%) remained BL/SVI
Level of visual impairment after cataract surgery due to posterior capsule opacifi-
  Blind 52 83.9% cation, amblyopia or coexisting retinal pathology.
  Severe visual impairment 10 16.1% Corneal scarring was the second most common
Other disability cause (17.7%) followed by retinal dystrophies (16.1%).
  Yes 5 8.1% Four children had other corneal opacities (6.5%) due
  No 57 91.9% to anterior segment dysgenesis and sclerocornea. The
Family history most common whole globe abnormality (11, 17.7%)
  Yes 23 37.1% was microphthalmos (6, 9.7%). There was 1 case of
  No 39 62.9% retinopathy of prematurity (1.6%).
History of consanguinity
  Yes 11 17.7%
  No 43 69.4%
Etiological Classification of Visual Loss
  Unknown 8 12.9%
(Table 4)
Age of onset
  Congenital 46 74.2%
Hereditary factors were the most common etiology
  Infantile 7 11.3%
of blindness, accounting for 45.2% (28) of the cases,
  ≥1 to < 5 yrs 6 9.7%
where there was a positive family history of another
  ≥5 to < 16 yrs 2 3.2%
similarly affected individual or a well-recognized or
  Unknown 1 1.6%
proven genetic abnormality in the absence of family
Previous surgery
history, according to WHO/PBL examination record
  Yes 17 27.4%
coding instructions.
  No 45 72.6%
In 38.7% (24) of cases the underlying etiology could
not be determined. Of these, the abnormality had been
TABLE 2  WHO categories of BL/SVI† and distribution of
present since birth in 29% (18). Cataract and glaucoma
visual acuity were equally responsible for 3.2% (2).
Visual acuity Childhood/postnatal disorders were the third most
WHO category (better eye) Number % common etiology of blindness, accounting for 11.3%
Blind NPL 16 16.8% (7) of the cases. Corneal scars were the predominant
Blind < 3/60–PL 36 37.9% postnatal factor, mainly attributed to eye infection
Severe visual impairment < 6/60–3/60 10 10.5% from measles (5, 8.1%). There were no definite cases of
Visual impairment < 6/18–6/60 26 27.4% vitamin A deficiency (VAD).
No impairment 6/18 or better 7 7.4%
Total 95 100.0%
†
BL = Blindness, SVI = Severe visual impairment, WHO = World Avoidable Causes of Blindness (Table 5)
Health Organization, NPL = no perception of light,
PL = ­perception of light
Overall, 50% (31 cases) of BL/SVI were potentially
avoidable: 12.9% (8 cases) were preventable and
The majority of children had no previous eye surgery 37.1% (23 cases) were treatable. Measles was the most
(45, 72.6%). Ten had cataract surgery, 3 had glaucoma common preventable cause of visual loss (8.1% of the
surgery, 1 had a trabeculectomy and enucleation of the total) while cataract (22.6%) was the main treatable
contralateral eye, 1 had cataract surgery and removal of cause.
Ophthalmic Epidemiology
 Childhood Blindness in Cambodia    229

Table 3  Anatomical classification of BL/SVI† in 62 children Table 5  Avoidable causes of BL/SVI†

attending schools for the blind in Cambodia Causes Number % of total
Anatomical site Number % of total Avoidable 31 50.0%
Whole globe 11 17.7% Preventable 8 12.9%
Microphthalmos 6 9.7% Measles 5 8.1%
Buphthalmos 1 1.6% Ophthalmia neonatorum 1 1.6%
Glaucoma 2 3.2% Infective keratitis 1 1.6%
Removed 1 1.6% Postnatal trauma 1 1.6%
Disorganized 1 1.6% Treatable 23 37.1%
Cornea 16 25.8% Cataract 14 22.6%
Staphyloma 1 1.6% Pseudophakia/aphakia 1 1.6%
Scar 11 17.7% Phakodenesis 1 1.6%
Other opacity 4 6.5% Glaucoma 3 4.8%
Lens 17 27.4% ROP‡ 1 1.6%
Cataract 15 24.2% Uveitis 1 1.6%
Aphakia 1 1.6% Retinal detachment 1 1.6%
Other 1 1.6% Refractive error 1 1.6%
Uvea 2 3.2% Unavoidable 31 50.0%
Uveitis 1 1.6% CEA†† (microphthalmos, 9 14.5%
Other 1 1.6% ­anophthalmos, coloboma)
Retina 13 21.0% Retinal dystrophies 10 16.1%
Dystrophy 10 16.1% Optic nerve disease (atrophy, 1 1.6%
ROP‡ 1 1.6% ­hypoplasia)
Other 2 3.2% Other 10 16.1%
Optic Nerve 2 3.2% Removed, phthisical, or disorganised 1 1.6%
Atrophy 1 1.6% †
BL=Blindness, SVI=Severe visual impairment,
Other 1 1.6%
‡
ROP=Retinopathy of prematurity, ††CEA=Congenital eye
abnormalities
Globe appears normal 1 1.6%
Refractive error 1 1.6%
Total 62 100.0% only for distance correction that were immediately
†
BL = Blindness, SVI = Severe visual impairment, dispensed.
‡
ROP = ­Retinopathy of prematurity Nineteen of the 21 children assessed for LVAs could
discern print ≤ 5mm (91%).
The majority of children required no further medi-
Table 4  Etiological classification of BL/SVI† in 62 children cal attention (44, 71%). Sixteen required surgery and
attending schools for the blind in Cambodia 3 required non-surgical treatments. The visual status
Etiological factor Number %
was likely to remain stable in 51.6% (32). The 27.4%
Hereditary disease 28 45.2%
(17) who had vision that could potentially be improved
Intrauterine 0 0%
through intervention and the 21% (13) who had vision
Perinatal/neonatal 3 4.8%
that was likely to deteriorate were referred to the local
Postnatal/infancy/childhood 7 11.3%
ophthalmologist.
Unknown 24 38.7%
The majority of children (44, 71%) attended only
Total 62 100.0%
their respective school for the blind. Eighteen attended
†
BL = Blindness, SVI = Severe visual impairment
an integrated school (29%). A change in schooling was
recommended for 2 children (following consultation
Action Needed in Children with the principal of the respective school) whose
visual acuity could be improved to better than 6/18
Thirty-two children had a pair of spectacles at pre- following refraction and prescription of spectacles
sentation. Twenty-nine children were believed to have (3.2%). We also advised that the 7 children without
useful vision (46.8%). Pinhole testing was performed impairment be transferred to a normal school to
in 26 children, with vision improving in 2 (3.2%). enhance their education and to make way for visually
Refraction was subsequently performed on 20 (32.3%) impaired children.
children. Despite the fact that 64.5% of the children were
The majority required no optical services (37, 59.7%), found to be BL/SVI, no student was seen to be using
however, 22.6% (14) required both spectacles and LVAs, a long cane. A total of 48 new long white canes were
12.9% (8) required LVAs only and 1 required spectacles donated, which were distributed equally to the local
© 2010 Informa UK Ltd
230    D. I. T. Sia et al.
teachers at the schools. The canes were specific for
children, and ranged in length from 34” to 48”.
Mobility aids such as ultra-violet shields were issued
directly to students when glare was identified as a
major issue.
It was found that O&M is included in the curricu-
lum and that all schools provide a basic level of O&M
training to their students. Basic O&M techniques are
taught to students to ensure they are safe, indepen-
dent travelers within the compounds of the school.
Skills such as sighted guide techniques, trailing, upper
body protection and searching for dropped objects are
taught. Students are also taught some basic orienta-
tion techniques including the use of hearing, touch
and smell. O&M training is typically only offered to
students in grades 1 and 2. It was found however, that
teachers had a lack of understanding in regards to the
scope of O&M training, with an underlying belief that
students who are blind or visually impaired cannot
travel safely and independently within the community
and therefore training is not typically taught beyond
the school’s compound.
Teachers employed at each school teach all aspects
of the school’s curriculum, including the specialized
skills such as Braille, O&M and daily living skills.
There are no teachers employed specifically to teach
O&M. Teachers have minimal opportunity to learn
O&M skills, with some having had an opportunity to
attend a two-week workshop in 2005 conducted by a
visiting instructor. In the majority of cases new teach-
ers learn their O&M skills and techniques from other
teachers at the school.
DISCUSSION
Cambodia has a population of 13.4 million people of
whom approximately 5.1 million are children under
15 years old.6 There is no formal blindness register for
children in Cambodia, however the estimated number
of blind children may be as high as 7,650 (1.5/1000 of
5.1 million children). The present study identified a
total of 62 BL/SVI children aged below 16 years in 4
schools for the blind, representing less than 1% of the
estimated prevalence of blind children in Cambodia.
The majority of blind and visually impaired children
are therefore not covered by schools for the blind.
Although the prevalence of blindness is higher in
adults, blindness in childhood has far reaching impli-
cations for the affected child and family. Children who
are born blind or who become blind have a lifetime
of blindness ahead of them, with all the associated
emotional, social and economic costs to the child, the
family and society.1 Many of the causes of blindness in
children are also causes of child mortality.
There is a preponderance of males over females
(56.8% vs. 43.2%) in this study, an observation seen
in other similar studies.9–12 Two population-based
studies from India have reported a much higher pro-
portion of blindness in female children compared to
males,13,14 which suggests that the preponderance of
males in schools for the blind is likely to reflect social
bias toward education of males rather than gender
­differences in causes of blindness.4
Of the 95 children in this study, over 65% were
BL/SVI, with the lens being the most common
major site of abnormality (27.4%) and the major-
ity of these being cataracts (24.2%). A similar pro-
portion of lens-related abnormalities was seen in
Malaysia15 (22.3%), Nigeria16 (30.4%), Mongolia17
(34%), Bangladesh18 (32.5%) and Uganda19 (30.7%).
However, the proportion of lens-related abnormali-
ties in Cambodia is higher than in most neighbor-
ing regions of South East Asia: Myanmar12 (14.4%),
Indonesia20 (14.6%), Thailand21 (16.9%), Philippines21
(9.7–16.8%) and Sri  Lanka22 (17.3%). Corneal scar-
ring was the second most common abnormality
(17.7%), mainly attributed to measles keratitis and
congenital abnormalities.
Hereditary disease (cataract, retinal dystrophy and
anterior chamber dysgenesis) was the most common
etiology and accounted for 45.2% of BL/SVI. The
majority of genetic disease was autosomal recessive
(14, 50%) and may be related to consanguineous mar-
riages. Consanguinity was confirmed in 17.7% (10) of
parents in this study and unknown in 12.9% (8). It is
favored to varying degrees in Cambodia, but there are
currently no reliable data on its prevalence.23 Health
education and genetic counseling have been shown to
be effective in preventing recessive diseases such as
thalassaemia in some populations,24 but a WHO expert
group has concluded that an attempt to discourage
consanguineous marriage on genetic grounds might
do more harm than good.25
The proportion of hereditary disease in this study
is one of the highest reported and is similar to stud-
ies from Indonesia (41.5%).20 Hereditary diseases
were also common in studies from Sri Lanka22 (35%),
India5,9,26 (up to 34.8%), Malaysia15 (29.5%), China11
(30.7%) and Mongolia17 (27%). Other neighboring
regions with lower hereditary diseases include Myan-
mar12 (11.9%), Thailand21 (13.8%) and Philippines21
(17.8%).
The cause of BL/SVI could not be determined in
38.7%, most of which abnormalities were present since
birth. The large proportion of undetermined etiology
is consistent with results from other studies using
similar methods and reflects the limited scope for
investigation, lack of examination of family members
and inadequate medical notes. Unknown causes also
Ophthalmic Epidemiology

predominate in studies from schools for the blind in
Malaysia, Myanmar, India, Indonesia, Thailand, Sri
Lanka, Bangladesh and China.5,10–12,15,18,20–22
Childhood factors were the third commonest
cause of BL/SVI (11.3%), the majority of these being
due to measles keratitis (8.1% of the total). This is
similar to childhood factors reported in Thailand
(12.3%), urban Philippines (15%), China11 (14%) and
Malaysia15 (7.8%), but higher than that reported in
Sri Lanka22 (5.3%) and lower than in studies from
India5,9,10,26,27 (11.1%–38.4%), Myanmar12 (33.2%), Indo-
nesia20 (28.5%), rural Philippines (57.1–61.3%) and
Bangladesh18 (30.7%). There were no definite cases of
VAD identified in this study, as opposed to studies
from India and Africa, where VAD accounted for up
to 18.6% and 70% of SVI/BL respectively. Minimal
nutritional blindness is also reported in studies from
Malaysia,15 Myanmar,12 Sri Lanka,22 China,11 and in
developed countries.2
Perinatal factors (cerebral hypoxia, ophthalmia
neonatorum, retinopathy of prematurity [ROP]) were
the least common, accounting for 4.8% of BL/SVI.
Only one case of ROP was detected. The low preva-
lence of ROP is similar to studies in Indonesia (Java),20
Myanmar,12 rural Philippines,21 and Sri Lanka22
where there is a scarcity of neonatal care facilities.
In more developed areas, such as urban Philippines21
and urban Indonesia,28 a higher incidence of ROP is
observed.
No intrauterine factors were identified in this study,
however this may be underestimated as there is a high
proportion of abnormalities present since birth with
undetermined etiology (29%) such as microphthalmos,
corneal abnormalities, optic atrophy, retinal dystro-
phies and aniridia.
Overall, 31 children (50%) had avoidable causes of
BL/SVI: 8 children had preventable causes (12.9%)
and 23 (37.1%) had treatable conditions. Approxi-
mately two-thirds of preventable causes were attrib-
uted to measles keratitis, the remainder were due to
ophthalmia neonatorum, postnatal trauma and infec-
tive keratitis. Over two-thirds of treatable causes were
due to lens-related abnormalities (cataracts, aphakia,
phakodonesis) and 13% of BL/SVI was due to glau-
coma. Other treatable causes included ROP, uveitis,
retinal detachment, and refractive errors. A total of 31
children (50%) had unavoidable causes, 14.5% being
due to congenital eye abnormalities and 16.1% due to
retinal dystrophies.
WHO’s VISION 2020 recommends that one pedi-
atric eye care centre (led by a pediatric ophthalmolo-
gist) be established for every 10 million population
within a country by the year 2020. There are currently
no pediatric eye care centers and no trained pediatric
ophthalmologists in Cambodia.
© 2010 Informa UK Ltd
Childhood Blindness in Cambodia    231
The pattern of BL/SVI seen in schools for the blind in
Cambodia fits the pattern in low-income communities
as described in Gilbert’s review paper4: approximately
equal proportion of cataract and corneal scarring.
Cataract is an increasingly important cause in poor
countries where there are established programs for
the control of measles and vitamin A deficiency.4 The
prevalence of measles in this study is a reflection of the
situation approximately 14 years ago (median age of
BL/SVI due to measles was 14 years with a range of
9–15 years). According to WHO/UNICEF estimates,
Cambodia had measles immunization coverage of 50%
in 1994; this has improved greatly since then to cover-
age of 89% in 2008. This however, is still lower than
in neighboring regions: Thailand 98% coverage and
Vietnam 92% coverage (2008 WHO/UNICEF estimates
of immunization coverage).
In other low-income countries such as Myanmar12
and rural Philippines,21 corneal scarring from measles
and VAD is still the predominant cause of BL/SVI.
The pattern of BL/SVI in Cambodia also differs from
middle-income countries (such as Latin American
countries), where ROP is often the most common cause.
In high-income countries, there is a high proportion of
perinatal and hereditary diseases.
The majority of children in these schools were in the
appropriate educational environment, however 35.5%
of children required optical correction or low-vision
aids. There is a need for improved optometric and low
vision services in Cambodia. Stand-magnifiers were
found to be the most effective LVA option, followed
by hand-held magnifiers.
The causes of BL/SVI identified in Cambodia are
likely to be biased as the large majority of visually
impaired children do not attend these schools and
those who do are likely from more privileged socio-
economic or ethnic backgrounds. Also, preschool chil-
dren and those with multiple disabilities are usually
not accepted into schools for the blind, leading to an
under-representation of these children in such studies.
Nevertheless, data on causes of BL/SVI from studies
of schools for the blind have been shown to be compa-
rable to data obtained from community-based studies,
as have been undertaken in Mongolia.17
Another limitation of this study was the inaccuracy
in differentiating between blindness present at birth
from that arising in the first year of life when we were
unable to confirm information from parents or medical
records.
The value of O&M training and the scope of what is
included in the curriculum appeared largely misunder-
stood in Cambodia’s schools for the blind. There was a
common belief that students who are blind cannot be
safe, independent travelers beyond the school grounds.
If appropriate O&M training is offered, students can
232    D. I. T. Sia et al.
develop the opportunities and skills that can broaden
their awareness of the environment, resulting in increased
motivation, independence and safety.29 This approach
has the flow-on affect of providing benefits to the whole
community by alleviating the burden of care.
It is therefore recommended that the teachers are
further educated and trained to understand the full
scope of O&M training and that training remains a part
of the regular school curriculum. Also, it is important
that students are given the opportunity to learn skills
that extend beyond the schools’ boundaries and into
the community. International blindness organizations
must be approached to provide ongoing O&M training
and teaching resources and support.
Conclusion
Approximately half of the children in schools for the
blind in Cambodia had potentially avoidable causes
of BL/SVI. Measles and cataracts were the commonest
preventable and treatable causes respectively; the data
supports the need for increased coverage of measles
immunization. There is also a need to develop spe-
cialized pediatric ophthalmic services for the manage-
ment of surgically remediable conditions, particularly
cataract, and to provide optometric and low vision
services. In response to the predominance of hereditary
diseases, genetic risk counseling services need to be
established, but with great caution as blame can often
be placed on the mother.
Acknowledgments
The authors would like to thank the Low Vision Centre
(Royal Society for the Blind) in Adelaide who donated
a range of LVAs for visually impaired children and
Rotary Club of Campbelltown who donated AU$1500
to purchase LVAs. Carolyn Hamilton from Guide Dogs
Association of SA & NT Inc who donated AU$1500 to
purchase a range of long white canes for blind chil-
dren and friends and family of Mr Martin Holmes
who raised AU$800 for the purchase of spectacles. The
authors would also like to thank the principal, staff
and children at each of the Krousar Thmey schools for
their help and cooperation during the survey.
The Vision Myanmar Fund of the South Australian Insti-
tute of Ophthalmology and The Fred Hollows Founda-
tion, Australia kindly funded the expenses associated
with undertaking the survey and analyzing the data.
Declaration of Interest: The authors report no conflicts
of interest. The authors alone are responsible for the
content and writing of the paper.
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